10/16/2018

BCBSM/BCN

Recent Oncology Related News

Provided by MSHO Managed Care Committee Members:

October 18, 2018 ICT Webinar: You've submitted a few claims; now what?

Have you submitted a few claims, but need help with the next step? If so, join us for an Internet Claim Tool webinar on Thursday, October 18, 2018, from 10 a.m. to 11 a.m. This webinar is designed for new professional ICT users. We will focus on how to assign claims to a new payer; the Payer Response Report; viewing transmitted claims; and resending edited claims. Please note attendees should have already submitted claims; this session is not intended as a first-time user's tutorial.

If you would like to participate, please click here to send an email with your first and last name, web-DENIS ID, company name, billing NPI and unique email address information to  edicustmgmt@bcbsm.com. We will supply login details prior to the training session.

Onpattro, Poteligeo, Signifor LAR added to medical benefit specialty drug prior authorization program for commercial members

The prior authorization program for specialty drugs covered under the medical benefit is expanding for BCN HMOSM and Blue Cross® PPO commercial members as follows:

These changes don't apply to BCN Advantage^SM, Blue Cross Medicare Plus Blue^SM PPO or Federal Employee Program^® members.

How to submit authorization requests
Submit authorization requests prior to the start of services for medical benefit drugs that require authorization using the NovoLogix^® web tool within Provider Secured Services.

Always verify benefits
Approval of a prior authorization request isn't a guarantee of payment. You need to verify each member's eligibility and benefits. Members are responsible for the full cost of medications not covered under their medical benefit coverage.

We’re adding a Documentation Guidelines tab to Benefit Explainer

To make it easier for you to find information about medical criteria, payment policies and procedure code updates, we’re adding a Documentation Guidelines tab to Benefit Explainer.

On Oct. 15, 2018, you’ll find the Documentation Guidelines tab in Benefit Explainer by:

• Clicking on the BPR tab.
• Clicking on Medical/Payment Policy Report.
• Clicking on the arrow to expand the Additional Information tab.
• Click Documentation Guidelines to view the information.

The information found under the Documentation Guidelines tab will still be available in The Record billing chart and web-DENIS alerts. Check out the November Record for more information, including screenshots of the change.

UPDATE: Claims failing for Diagnosis Code

The issue causing the error 'Diagnosis Code – Code Invalid; Check Service Dates Given' to appear on claims incorrectly has been resolved, and affected claims should no longer show the edit.

Once users view the claims, and save and run edits, the edit will be removed from the affected claims.

We apologize for any inconvenience this may have caused.

Some medical benefit drugs for Medicare Advantage members need step therapy, starting January 1

In the new year, according to Centers for Medicare & Medicaid Services guidance, certain Medicare Part B specialty drugs will have additional step therapy authorization requirements. This will apply to Medicare Plus Blue^SM PPO and BCN Advantage^SM members for dates of service on or after Jan. 1, 2019.

Step therapy is treatment for a medical condition that starts with the most preferred drug therapy and progresses to other drug therapies only if necessary. The goal of step therapy is to encourage better clinical decision-making.

What's changing?
For drugs requiring step therapy, authorization request questions will be different from the ones you currently answer. Some examples of drugs that require step therapy are:

• Botox^® for migraines and over active bladder 
• Eylea^®,Lucentis^® and Macugen^® for neovascular age-related macular edema 
• Prolia^® for osteoporosis

Use NovoLogix^® to submit authorization requests
We encourage you to send prior authorization requests for Medicare Part B specialty drugs through the NovoLogix web tool via Provider Secured Services. It's the most efficient way to get a determination.

Look for more information on step therapy requirements in upcoming issues of The Record and BCN Provider News.

Medical records requests will begin for commercial initiatives, Oct. 2018

In Oct. 2018, Ciox Health will begin requesting medical records for commercial patients. Ciox may ask for your help to provide complete medical records for your list of patients who were treated in your office in 2018.

The Centers for Medicare & Medicaid Services requires that Blue Cross and BCN satisfy standards for patient data submission and diagnosis coding accuracy. This medical record review is to confirm that we're meeting CMS and Department of Health and Human Services' requirements.

If you have questions, please contact one of the following Blue Cross and BCN provider consultants:

• Tom Rybarczyk, 313-378-8259
• Corinne Vignali, 313-969-0417
• Sue Brinich, 586-839-8614

Reminder: Follow these guidelines when billing medical drugs that haven’t been purchased

Some health care providers have questioned what to do when billing certain medical drugs that were administered by a medical professional but supplied by our specialty pharmacy.

Here are guidelines to follow in professional and hospital settings:

• When professional providers administer a drug they didn’t purchase, they should bill for the administration code only and not include the drug or NDC code on the claim.
  • When professional providers administer a medical drug that was purchased, notes should be documented and a copy of the purchase order included in the member’s chart.
  • Identical NDC codes billed within 14 days of a specialty pharmacy claim will be recovered and the provider will need proof of purchase to have the claim repaid.
• When a hospital administers a drug in an outpatient setting that isn’t purchased by the hospital, the hospital should bill for the administration. However, the hospital should include the revenue code and corresponding procedure code for the medical drug with total charges of $.01.

For more information, see the May 2016 and July 2016 Record articles.

October 2018 – Issue

• Blue Cross PPO members who live outside Michigan will need prior authorization for certain services
• We’re simplifying provider appeals process
• Most providers are missing out on medication reconciliation reimbursements. Are you?
• URMBT to participate in medical drug prior authorization program
• New utilization management programs beginning for URMBT members

CHECK OUT THESE ARTICLES AND MUCH MORE HERE!